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CHAMP-Manatee's Operation Protect & Secure
Exercise Registration (2018)
Thank you for taking the time to register for the Operation Protect & Secure exercise, taking place on Wednesday, November 7, 2018. Please complete the form below in its entirety.
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1.
What type of group do you represent?
Hospital
Long-Term Care
Rural Health Clinic / Federally Qualified Healthcare Center
Home Health Agency
Ambulatory Surgical Center
Hospice
Dialysis
EMS
Public Health
Emergency Management
Other (please specify):
2.
Organization Name:
3.
Organization Address (including city, state & zip):
4.
County(ies):
5.
Organization Point of Contact (POC):
6.
POC Email Address:
7.
POC Phone Number:
8.
Please estimate the number of people in your organization that will participate in Operation Protect and Secure:
